| Please print or type: |
| Name: |
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| Address 1 |
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| Address 2 |
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| City/ State/ Zip |
______________________________________________ |
| Telephone: |
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Print, Fill Out and Send form plus $10.00 Membership Fee to:
Wanda King / Secretary Treasurer
620 S. Petunia Road
Wytheville, VA 24382
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